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A total of 154 episodes of infective endocarditis (IE) in 149 patients were studied retrospectively with special regard to the major aetiological groups and the surgical evaluation. There were 136 episodes of native valve endocarditis (NVE) (88%) and 18 episodes of prosthetic valve endocarditis (PVE) (12%). Three major groups of NVE crystallized: Streptococcus viridans in 37 (27%), Staphylococcus aureus in 39 (29%) and culture negative IE in 28 (21%) episodes. In these groups surgery during the active phase was required in 41, 28 and 18%, respectively. At the operation myocardial abscess was found in as many as 7/15 cases with S. viridans, but in only in 3/11 cases with S. aureus and 1/5 cases with culture negative IE. The mean duration of preoperative antibiotic treatment was 34 d. This long period of unsuccessful pharmacotherapy, preceded by a mean of 47 d from start of symptoms to admission to hospital, has probably resulted in the high frequency of myocardial abscess in S. viridans NVE. Surgical evaluation should be considered when fever persists beyond 10 d of adequate treatment, even in the absence of clinically apparent complications. Among the PVE episodes, 11/18 were managed with pharmacological treatment alone. Uncomplicated PVE may thus often be successfully treated with antibiotics alone.

Background and Aims of the Study: The aims of this study were to evaluate symptomatic improvement and event-free/overall survival after balloon aortic valvulotomy in patients with significant sclerotic aortic valve stenosis., Methods: Sixty-four patients with calcified aortic stenosis, in NYHA class III-IV, and of mean age 79.0 years, underwent a total of 75 scheduled attempts at balloon aortic valvulotomy, with single balloon catheters between December 1987 and June 1993. Patients were either considered as poor surgical candidates or themselves preferred such valvulotomy., Results: Periprocedural major complications, including death in 6%, occurred in association with 16% of the procedures. Among 57 patients in whom initial dilatation was successful, the average period of symptom relief was 9.4 months (median 7.0, range: 0 to 47 months). Independent predictors for longer duration of symptom relief and survival were systolic arterial pressure > 115 mmHg and female gender; ejection fraction > or = 30% was only predictive of survival. Actuarial survival rates at one, two and three years were 77, 48 and 36% respectively., Conclusions: Balloon aortic valvulotomy is followed by a short period of symptomatic relief and carries a low periprocedural mortality, but considerable morbidity. By comparison, aortic valve replacement patients aged over 70 and with serious physical limitations (NYHA class IIIB-IV) showed much better overall survival. As contraindications to surgery are in most cases relative, aortic valve replacement should always be considered as the only choice in the surgical decision-making.

The acute hemodynamic response to captopril (8 patients) and enalapril (8 patients) was evaluated in congestive heart failure patients in NYHA functional class III. All patients had a history of congestive heart failure for more than six months. The results show marked interindividual variations but average values for cardiac output increase and decrease in filling pressures agree with findings in the literature. 6 patients in the captopril group and five in the enalapril group were started on maintenance therapy. One patient in the captopril group deteriorated and underwent a successful heart transplantation and one patient in the enalapril group returned with arrhytmias and hypertension (probably not drug-related) after 48 h of therapy. Our data indicate that activation of the renin-angiotensin system through excessive administration of loop-diuretics is associated with a risk of hypovolemia and thus drug-induced hypotension that deserves special attention when considering converting enzyme inhibitor therapy in congestive heart failure.

The long-term results of open-heart valve surgery in Uppsala in the period 1959-1974 were reviewed. The total number of patients operated on was 677 and the mean follow-up time was 10 years (range 5-22 years). The operative mortality was high in the early years, but fell to 11-12% towards the end of the period. The main long-term complication was embolism. The frequency of late reoperation was 10-20%, reflecting the limited durability of the early mechanical valves and of subsequently used biologic valves. The actuarial 10-year survival, calculated as 50%, was approximately equal among the patients with aortic and those with mitral valve disease. The predominant late causes of death (60-75%) were 'cardiac', including myocardial as well as valve-related causes. Follow-up investigation comprised 244 survivors. In general there was considerable functional improvement both in the aortic and in the mitral group. Valvular insufficiency leading to reoperation was detected at follow-up examination in 6-8% of the patients.

The ejection fraction of the left ventricle was determined by videodensitometry in 121 patients with angina pectoris. The mean value was 31 per cent. This estimation, which is easily performed by the method described, gives important and accurate information on the left ventricular function which, added to other parameters, should increase the reliability of the clinical evaluation of the patient.

Seventy-eight patients were included in a prospective study of the cardiac risk in abdominal aortic surgery. The Goldman risk score and the American Society of Anesthesiologists (ASA) classification system were applied besides several individual clinical risk factors. Thirty-three patients developed some kind of cardiac event, 13 of which were myocardial infarctions leading to death in six patients. Computer aided stepwise logistic procedure was used to determine risk factors independently correlated with these complications. This study showed that the Goldman risk score, angina, hypertension and renal insufficiency were significantly correlated with postoperative cardiac complications while no correlations were demonstrated with history of myocardial infarction, chronic heart failure or the ASA score system. A high incidence of cardiac complications (32%) was also found in the low-risk category in the Goldman score system, which indicates the need for cardiac function tests before abdominal aortic surgery.

Exercise-induced changes in the ST segments of the electrocardiogram were compared with the results of coronary arteriography in 73 consecutive patients referred for preoperative evaluation of coronary artery disease. Eighteen patients had single-, 25 double-, and 30 triple-vessel disease. Thirteen were taking digitalis alone, 28 were taking beta blockers alone, 21 had beta blockers and digitalis and 11 had no cardiac drugs. Exercise induced elevation of the ST segment in 11 patients, all with a predominant lesion in the left anterior descending coronary artery. ST depression with an upsloping ST segment was observed in patients with one-, two-, and three-vessel disease and it was the most common type of ST change in patients with single-vessel disease. Horizontal ST depression was most common in two-vessel disease and downsloping ST segment in three-vessel disease. There was a good correlation between the number of stenosed vessels and ST changes caused by exercise, expressed as the sum of ST segment displacements in twelve leads recorded immediately after the end of exercise (sigma/ST/) or as ST depression per unit increase in heart rate during exercise ("m" (ST/HR]. The latter was obtained by linear regression of ST displacement and heart rate measured at three or four different workloads in the lead with the greatest displacement of the ST segment. The mean values of sigma/ST/ were 0.58 +- 0.030 mV in single-vessel, 0.97 +- 0.41 mV in double-vessel and 1.58 +- 0. 46 mV in triple-vessel disease. The mean values of "m" (ST/HR) were 0.0024 +- 0.0013 mV X min-1 X beat-1 in single-vessel, 0.0042 +- 0.0012 in double-vessel, and 0.0078 +- 0.0033 in triple-vessel disease. These differences were highly significant (p less than 0.01 - 0.001) and there was only minimal overlap between the single- and triple-vessel groups. Digitalis caused a slight (statistically nonsignificant) increase in sigma/ST/ but not in "m" (ST/HR).

A case of malignant leiomyosarcoma presenting as a left atrial cardiac tumor is described and its echocardiographic features are discussed. Tumor masses invading the atrial walls were extensively resected and the atrial wall was reconstructed with two patches of bovine pericardium.

One-hundred-and-thirteen patients with endocarditis and valvular insufficiency were studied retrospectively with special regard to indications for operation and the optimum time for cardiac valve surgery. Thirty patients (group I) had acute, 63 (group II) subacute and 20 (group III) prosthetic valve endocarditis. Group I: Eleven patients underwent surgery in the acute stage, 8 while bacteremic; 5 of the latter died perioperatively. Of the 19 patients treated medically, 16 died. Group II: All patients underwent operation in a bacteria-free state. The mortality was 5%. Group III: Eight patients had early (less than 60 days postoperatively) and 12 late endocarditis. Total mortality was 40% (71% early and 25% late mortality). Ten patients underwent reoperation, with a mortality of 20%, compared with 60% in the medically treated group. The results support the indication for early operation in acute endocarditis with progressive cardiac failure and renal failure and prosthetic valve endocarditis, even during bacteremia.

In fourteen patients referred for preoperative evaluation of heart disease we compared the transthoracic electrical impedance method to the direct Fick (four patients) and dye dilution methods (ten patients) for estimation of cardiac output. On statistical analysis of paired differences we found no reliable agreement between the absolute impedance values and the reference methods. The reproducibility was, however, acceptable, and the coefficient of variation for impedance cardiac output was 7.8%, and for impedance stroke volume 7.6%. Our conclusion is that in patients with advanced heart disease cardiac output cannot be determined with accuracy with the impedance cardiographic method. In clinical practice this must be considered so important, that we hesitate to use the method for monitoring cardiac output in critically ill patients even if the reproducibility for individual changes is acceptable.

The videodensitometer has been used in a group of 20 patients with aortic incompetence and incompetence combined with stenosis. The method appears effective in the preoperative evaluation of the valvular and ventricular function of the patient. It gives objective and probably more accurate information of the regurgitation fraction and the ejection fraction than the commonly used semiquantitative methods. The method is simple to use and needs no technical changes in the roentgen equipment.